Friday, March 5, 2010

Early in 2009, members of major health care–related industriessuch as insurance companies, pharmaceutical manufacturers, medicaldevice makers, and hospitals all agreed to forgo some futureprofits to show support for the Obama administration's healthcare reform efforts. Skeptics have questioned the value of thesepromises, regarding at least some of them as more cosmetic thansubstantive. Nonetheless, these industries made a gesture andscored some public-relations points.

The medical profession's reaction has been quite different.Although major professional organizations have endorsed variousreform measures, no promises have been made in terms of cuttingany future medical costs. Indeed, in some cases, physician supporthas been made contingent on promises that physicians' incomewould not be negatively affected by reform.

It is appropriate to question the ethics of organized medicine'spublic stance. Physicians have, in effect, sworn an oath toplace the interests of the patient ahead of their own interests— including their financial interests. None of the for-profithealth care industries that have promised cost savings havetaken such an oath. How can physicians, alone among the "specialinterests" affected by health care reform, justify demandingprotection from revenue losses?

Physicians might insist that they should be immune from incomeloss if the causes of excessive health care costs are beyondtheir control. The American Medical Association (AMA), for example,addresses cost containment almost solely by calling for malpracticereform, suggesting that high costs are the fault of the legaland not the medical system.1

Unfortunately, the myth that physicians are innocent bystandersmerely watching health care costs zoom out of control cannotbe sustained. What we now know about regional variation in costswithin the United States suggests that nearly one third of healthcare costs could be saved without depriving any patient of beneficialcare, if physicians in higher-cost regions ordered tests andtreatments in a pattern similar to that followed by physiciansin lower-cost regions.2 We also have good reason to believethat physicians in lower-cost regions order and provide evidence-basedtests and treatments just as often as their higher-cost colleaguesdo, but they tend to avoid providing care whose usefulness isnot well supported by existing evidence.3 In short, U.S. physicianscould do a great deal to control costs if they were willingto practice more in accordance with evidence-based guidelinesand to study more seriously the data on regional practice variations.

Physicians should recognize that the high cost of future medicalcare is one of the main stumbling blocks to the passage of healthcare reform legislation that would extend insurance coverageto most Americans who now lack it. Physicians know from experiencehow people's health is placed at risk when they lack insuranceand access to basic, timely care. A profession that has swornto put the patient's interest first — to conduct itselfas a profession and not merely as a business — cannotjustifiably stand idly by and allow legislation that would extendbasic access to care to go down to defeat while refusing tocontemplate any meaningful measures it might take to reducehealth care costs.

In my view, organized medicine must reverse its current approachto the political negotiations over health care reform. I wouldpropose that each specialty society commit itself immediatelyto appointing a blue-ribbon study panel to report, as soon aspossible, that specialty's "Top Five" list. The panels shouldinclude members with special expertise in clinical epidemiology,biostatistics, health policy, and evidence-based appraisal.The Top Five list would consist of five diagnostic tests ortreatments that are very commonly ordered by members of thatspecialty, that are among the most expensive services provided,and that have been shown by the currently available evidencenot to provide any meaningful benefit to at least some majorcategories of patients for whom they are commonly ordered. Inshort, the Top Five list would be a prescription for how, withinthat specialty, the most money could be saved most quickly withoutdepriving any patient of meaningful medical benefit. Examplesof items that could easily end up on such lists include arthroscopicsurgery for knee osteoarthritis and many common uses of computedtomographic scans, which not only add to costs but also exposepatients to the risks of radiation.4,5

Having once agreed on the Top Five list, each specialty societyshould come up with an implementation plan for educating itsmembers as quickly as possible to discourage the use of thelisted tests or treatments for specified categories of patients.Umbrella organizations such as the AMA might push hard on specialtysocieties and pressure the laggards to step up.

Some societies will be tempted to bluff their way through theTop Five exercise, deliberately omitting cost-cutting measuresthat would particularly affect members' revenue streams. Societiescould display their professional seriousness by submitting theirlists for review and comment to several societies in other specialties.

Some would object that considerably more comparative-effectivenessresearch is needed before such lists can be compiled and implementationstrategies developed. And indeed, today we have no idea howto implement a practical plan that would recapture the roughly30% of health care expenditures estimated to be wasted on nonbeneficialmeasures.2 I would guess, however, that if we were trying tosave that entire sum of money, we would be proposing "Top Twenty"or "Top Fifty" lists for many specialties, not just the TopFive. I suggest that no matter how desirable more research is,we know enough today to make at least a down payment on medicine'scost-cutting effort. As good citizens and patients' advocates,we should begin where we can.